Lee, Kwan

Background Although myocardial infarction with nonobstructive coronary arteries (MINOCA) is more common in women, it is unknown whether sex is a risk factor for adverse outcomes in patients with MINOCA. We aimed to investigate the relationship between sex differences and outcomes of patients with MINOCA. Methods and Results A systematic literature search was performed in PubMed, Embase, and Cochrane databases from their inception until August 2023 for relevant studies. End points were pooled using the Hartung–Knapp–Sidik–Jonkman random‐effects model as odds ratio (OR) with 95% CIs. Nine studies, involving 30 281 patients with MINOCA (comprising 18 079 women and 12 202 men), were included in the study. Women were older and had a higher prevalence of hypertension, diabetes, and stroke compared with men. The median duration of follow‐up was 3.5 years, with an interquartile range of 2.2 to 4.2 years. Pooled analysis revealed no statistically significant difference in the risk of all‐cause mortality (OR, 1.03 [95% CI, 0.87–1.22]), major adverse cardiovascular events (OR, 1.18 [95% CI, 0.89–1.58]), heart failure (OR, 1.32 [95% CI, 0.57–3.03]), stroke (OR, 1.13 [95% CI, 0.56–2.26]), and myocardial infarction (OR, 1.04 [95% CI, 0.29–3.76]) between the 2 groups. Regarding short‐term outcomes, women had a significantly higher risk of in‐hospital major adverse cardiovascular events compared with men (OR, 1.33 [95% CI, 1.16–1.53]) whereas there was no significant difference in the risk of in‐hospital mortality (OR, 0.90 [95% CI, 0.64–1.28]) between the 2 patient groups. Conclusions Despite the differences in demographics and comorbidity profiles, there was no significant difference in the long‐term outcomes for patients with MINOCA between sexes. However, it is noteworthy that women experienced a higher risk of in‐hospital major adverse cardiovascular events compared with men.

Abstract Aims Lipoprotein(a) [Lp(a)] has demonstrated its association with atherosclerosis and myocardial infarction. However, its role in the development of in-stent restenosis (ISR) after percutaneous coronary intervention (PCI) is not clearly established. The aim of this study is to investigate the association between Lp(a) and ISR. Methods and results A retrospective study of adult patients who underwent successful PCI between January 2006 and December 2017 at the three Mayo Clinic sites and had a preprocedural Lp(a) measurement was conducted. Patients were divided into two groups according to the serum Lp(a) concentration [high Lp(a) ≥ 50 mg/dL and low Lp(a) < 50 mg/dL]. Univariable and multivariable analyses were performed to compare risk of ISR between patients with high Lp(a) vs. those with low Lp(a). A total of 1209 patients were included, with mean age 65.9 ± 11.7 years and 71.8% were male. Median follow-up after baseline PCI was 8.8 [interquartile range (IQR) 7.4] years. Restenosis was observed in 162 (13.4%) patients. Median serum levels of Lp(a) were significantly higher in patients affected by ISR vs. non-affected cases: 27 (IQR 73.8) vs. 20 (IQR 57.5) mg/dL, P = 0.008. The rate of ISR was significantly higher among patients with high Lp(a) vs. patients with low Lp(a) values (17.0% vs. 11.6%, P = 0.010). High Lp(a) values were independently associated with ISR events (hazard ratio 1.67, 95% confidence interval 1.18–2.37, P = 0.004), and this association was more prominent after the first year following the PCI. Conclusion Lipoprotein(a) is an independent predictor for long-term ISR and should be considered in the evaluation of patients undergoing PCI.

Cardiogenic shock is the most common cause of mortality in patients with acute myocardial infarction with an increase in incidence over the last 15-years. Recent classification systems of cardiogenic shock (CS) have improved categorization of patients into subsets of acuity and begun to integrate phenotypes and etiologies in addition to risk modifiers. Early revascularization with PCI or CABG has been the most important advance in the management of AMI-CS patients with improvements in survival. Despite this initial progress, mortality remains high at approximately 40%, with a significant proportion of patients dying of neurological causes, especially in the cohort with cardiac arrest and multi-organ dysfunction despite cardiac recovery. Mechanical circulatory support devices are an attractive strategy to ameliorate the cardio-metabolic spiral but have thus far failed to show survival benefits in randomized trials during revascularization of AMI-CS patients with IABP and ECMO use, although many aspects of their use have yet to be studied, including their role as part of an escalation or bridging strategy along the continuum of CS care. Randomized trials in Impella percutaneous LVAD use are pending. Cardiac arrest patients represent an important cohort with specific challenges of care and familiarity with management including the use of mechanical CPR devices, temperature optimization, MCS use and pharmacotherapy issues are critical to successful outcomes.

Background Percutaneous heart valve procedures have been increasingly performed over the past decade, yet real‐world mortality data on valvular heart disease (VHD) in the United States remain limited. Methods and Results We queried the Centers for Disease Control and Prevention's Wide‐Ranging Online Data for Epidemiologic Research database among patients ≥15 years old from 1999 to 2020. VHD and its subtypes were listed as the underlying cause of death. We calculated age‐adjusted mortality rate (AAMR) per 100 000 individuals and determined overall trends by estimating the average annual percent change using the Joinpoint regression program. Subgroup analyses were performed based on demographic and geographic factors. In the 22‐year study, there were 446 096 VHD deaths, accounting for 0.80% of all‐cause mortality (56 014 102 people) and 2.38% of the total cardiovascular mortality (18 759 451 people). Aortic stenosis recorded the highest mortality of VHD‐related death in both male (109 529, 61.74%) and female (166 930, 62.13%) populations. The AAMR of VHD has declined from 8.4 (95% CI, 8.2–8.5) to 6.6 (95% CI, 6.5–6.7) per 100 000 population. Similar decreasing AAMR trends were also seen for the VHD subtypes. Men recorded higher AAMR for aortic stenosis and aortic regurgitation, whereas women had higher AAMR for mitral stenosis and mitral regurgitation. Mitral regurgitation had the highest change in average annual percent change in AAMR. Conclusions The mortality rate of VHD among the US population has declined over the past 2 decades. This highlights the likely efficacy of increasing surveillance and advancement in the management of VHD, resulting in improved outcomes.

ABSTRACT Coronary bifurcation lesions and treatment with two-stent techniques have been developed, including the double kissing (DK) crush technique. The use of this technique in children or noncoronary vessels, including pulmonary arteries, has not been described. We present a 12-year-old girl with Alagille syndrome, a ventricular septal defect (VSD), and complex bilateral pulmonary artery (PA) stenoses who is status post six catheterizations for PA angioplasty and stenting to improve her marked right ventricular hypertension. With collaboration between the congenital and structural teams, she successfully underwent the DK crush technique for a complex lesion in her PA. This improved pulmonary flow and allowed for successful surgical VSD closure.

Background: While spontaneous coronary artery dissection (SCAD) patients can present with ventricular arrhythmias (VAs), the in-hospital outcomes among these patients are not well-established. Objective: This study aimed to analyze the in-hospital outcomes of patients with SCAD and concurrent VAs, and to determine the predictors of VAs occurrence in this population. Methods: Using the Nationwide Readmissions Database, our study included patients aged 18 years or older who had SCAD between 2017 and 2020. We categorized the cohort into two groups depending on the presence of VAs during hospitalization. The in-hospital outcomes were assessed between two groups. Through multivariable analysis, we further analyzed the predictors of VAs occurrence among SCAD patients. Results: Our study included 160 (13.45%) SCAD patients with concurrent VAs and 1,030 (86.55%) SCAD patients without concurrent VAs between 2017 and 2020. SCAD patients with concurrent VA were associated with higher rates of early mortality (11.88% vs. 2.04%, p<0.01), prolonged index hospital stay (≥7 days) (31.25% vs. 12.82%, p<0.01), and non-home discharge (21.88% vs. 6.50%, p<0.01). The length of hospital stay was longer in the SCAD with concurrent VAs group (6.93 days vs. 3.73 days, p<0.01), and the median cumulative cost of hospitalization was also higher in this group ($31,450 vs. $14,664, p<0.01). SCAD with concurrent VAs patients also had poorer in-hospital adverse events. In multivariable analysis, the independent predictors for VAs occurrence among SCAD patients were chronic liver disease (aOR: 2.18; 95% CI: 1.15- 4.12, p=0.02) and heart failure (aOR: 3.40; 95%CI: 2.30- 5.02, p<0.01). Conclusion: Ventricular arrhythmias among SCAD patients were associated with poorer in-hospital outcomes. Heart failure and chronic liver disease were the predictors of VAs in SCAD patients. This highlights the importance of closely monitor and aggressive VAs management among these high-risk patients.

Background: Despite advancements in the management of cardiac amyloidosis, the contemporary estimates of the cardiovascular deaths (CVDs) in amyloidosis are not well-established. Objective: This study sought to assess the longitudinal trends of CVDs with comorbid amyloidosis and analyze the disparities in mortality in terms of race, gender, and geographical location. Methods: We queried the Centers for Disease Control and Prevention's Wide-Ranging Online Data for Epidemiologic Research database and performed serial cross-sectional analyses of national death certificate data for cardiovascular mortality with comorbid amyloidosis among patients aged 25 and above. Diseases of the circulatory system (ICD-10 I00-I99) were listed as the underlying cause of death, and amyloidosis (ICD-10 E85) as contributing cause of death. We calculated age-adjusted mortality rates (AAMRs) per 1,000,000 individuals and determined the trends over time by estimating the annual percent change using the Joinpoint Regression Program. Results: In the 22-year study period, 4,145 CVDs with comorbid amyloidosis in the United States were identified between 1999 and 2020. The AAMRs increased significantly from 0.69 per 1,000,000 individuals in 1999 to 2.13 per 1,000,000 individuals in 2020 (p< 0.05), with an annual percent increase of +3.92. The AAMRs for the span of 22 years were higher in males than females (1.66 vs. 0.75, p<0.05). When stratified by race, African American populations had the highest cumulative AAMR (2.34) compared to other racial groups. In terms of urbanization, the AAMR was significantly higher in the urban regions compared to the rural areas (1.15 vs. 0.91, p<0.05). Conclusion: The AAMRs from CVDs with comorbid amyloidosis have increased significantly over the past two decades, with significant disparities in male and African American individuals. This emphasises the need of further research in the development of effective treatments for amyloid heart disease.

A 41-year-old female with hyperlipidemia presented with typical exertional angina, dyspnea, and pre-syncope of 6 months duration. Physical examination was unremarkable. ECG showed low voltage QRS (Figure A), and Chest CTA was negative for obstructive-CAD, pulmonary emboli, aortic, and lung disease. Cardiac MRI was negative for myocarditis/pericarditis . Resting TTE was unremarkable with normal systolic and diastolic function. NT-Pro BNP, hs-CRP, serum/ urine protein electrophoresis, and free light chains ratio were normal. Regadenoson PET myocardial perfusion test showed a medium-sized area of stress-induced ischemia in mid/apical segments (Figure B) . Resting right heart Cath showed mean RA pressure (9mmHg) and RVEDP (10mmHg), mean PA pressure (19mmHg), and PCWP (15mmHg) with large v-waves, PCWP increased to 28mmHg with limited supine bike exercise, diagnostic of HFpEF (Figure C) . Angiography showed normal coronary arteries while coronary reactivity testing was diagnostic of severe epicardial and microvascular endothelial dysfunction (60% mid/distal LAD constriction and 19% decreased blood flow in response to intracoronary (IC) acetylcholine), and endothelial-independent microvascular dysfunction (coronary flow reserve 2.4 in response to IC adenosine), diagnostic of HFpEF due to coronary endothelial and microvascular disease (Figure D) . The patient’s symptoms improved at 2 weeks follow-up after initiation of furosemide, diltiazem, isosorbide mononitrate, and atorvastatin.